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Feds help health insurers hide their dirty secret: denials on the rise

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Re: Feds help health insurers hide their dirty secret: denials on the rise

#281

Post by wat10000 »

refurb wrote: post #278
wat10000 wrote: post #104

Earlier quoted context omitted.

The difference is that patients in the US are being denied by people lining their own pockets with the savings. In sane countries, there’s at least some basis of trying to do the most good with the resources at hand, which sometimes means denying care for person A because those resources would be better spent on person B. With private insurers in the US, it means denying care for person A because they think they can…

> With private insurers in the US, it means denying care for person A because they think they can get away with it and it will increase their profits. The person at the insurer who denies a claim is not making more money because they denied it. The company as a whole might, but not the person denying it.

Right, the ones who profit are just setting up the rules, policies, and incentive structures that those people work under.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#282

Post by devilbunny »

OutOfHere wrote: post #216
devilbunny wrote: post #92

Earlier quoted context omitted.

I'm an anesthesiologist. What they denied was paying me to do it. You can still get "moderate sedation" from a nurse - a benzodiazepine and opioid. Patients strongly prefer having what amounts to a general anesthetic; your chances of recalling anything are low either way, but propofol results in a much faster recovery to full consciousness afterward. Go gain 100 pounds and develop sleep apnea. Then they'll approve it…

Propofol (or equivalent) is a must. I know people who have had a colonoscopy without it, and have regretted it due to significant pain. Note that they approved the colonoscopy, just not the anesthetic. Also, to get approval for a colonoscopy, one just needs to have persistent intestinal pain or note that they have a history of polyps.

I am well aware of the colonoscopy rules. I struggle with them when patients who would not meet the standard are scheduled with us because they are employees of the hospital and it will not pay for care outside the system. It is one of the many factors that goes into the hospital’s subsidy to my group. Most of these are too ill to be done in a non-hospital facility - though most do fine and go home, there are some we have to admit overnight for observation.

It is almost universal that hospitals pay from their fees for part of the anesthesia services because the direct reimbursement we get is so low.

You can get one at 45, no questions asked, or you can claim you had a bloody stool.

As far as pain, that’s hard to measure. Procedures that are done under sedation or anesthesia in the US are done in other countries with little or nothing. I had all of my wisdom teeth extracted and all of my dental fillings done under local anesthesia only. It was fine. I don’t need gas, I don’t need sedatives.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#283

Post by skeaker »

nradov wrote: post #265
skeaker wrote: post #258

Earlier quoted context omitted.

This obviously goes without saying. In fact, I'm not sure how implementing a system like Germany or Japan has would impact this at all.

I'm not sure how implementing a system like Germany or Japan wouldn't impact those things at all. Why aren't Germany or Japan equal to the USA in 5-year cancer survival rates? Their systems optimize for different priorities, and those involve trade-offs. So no, it obviously doesn't go without saying. If we want to cut overall health system costs or improve access then we might have to accept some reduction in service…

Perhaps because the US is the home of a number of prestigious colleges and to be with your peers you have to relocate there? You act like the broken healthcare system is the only possible explanation for cases where the US provides better care, but I'm yet to see that proven. Intuitively it doesn't track because many of the issues with the system don't pertain to things like intensive cancer care but to simple things that are of the exact same quality in countries with better systems, such as insulin where the only difference in the US is the price.

Not to mention, your comparison on cancer survival rates is flawed. The US system drives many people with cancer to be completely unable to afford treatment, which I doubt you've factored into your survival rate number.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#284

Post by refurb »

axus wrote: post #219
fny wrote: post #195

Earlier quoted context omitted.

Yes, insurance companies deny claims, but this is mostly because they don't have the money to pay for things most of their money is spent on care in the first place: they're forced to optimize and people get hurt in the process. Providers do far more damage. UHCs profit margins are only 6%, their operating costs are extremely low[0], and if you look across G7 insurers in the US pay more than the government does in ev…

Why are the providers behaving differently and in different circumstances in US vs. Japan/Germany/France?

They aren’t.

Doctors in Canada went on strike when nationalized healthcare was pursued by the government in the 60’s.

The government broke the strike by importing foreign doctors.

https://en.m.wikipedia.org/wiki/Saskatchewan_doctors%27_stri...

In those other countries doctors power was significantly curtailed long long ago.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#285

Post by refurb »

mancerayder wrote: post #217

Let the health insurance companies deny claims. But then let the medical providers duke it out behind the scenes! Leave patients alone and don't send them bills six months later.

This is actually key.

The problem today is the insurers, hospitals and doctors put the patients at the center of the fight.

Insurance denied? You pay patient.

Insurance didn’t pay doctor enough? You pay patient.

Hospital not in network? You pay patient.

I think patients would see it as an improvement if hospital said upfront to go somewhere else as insurance won’t pay. If they knew insurance would pay at the right hospital than it would be better than today’s situation.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#286

Post by dogboat »

mancerayder wrote: post #217

Let the health insurance companies deny claims. But then let the medical providers duke it out behind the scenes! Leave patients alone and don't send them bills six months later.

Assuming you are a coder lets see how that works for you..

Someone comes to you saying they need a website. You say "absolutely ... clearly you need one!". So you build it.

The decision to pay you however comes from some 3rd party who says "denied". Now the customer keeps their site and you don't get paid.

Will you stay in this coding business?

The real solution is a public health system. Which has issues (apply queuing theory, because you will have to wait for the limited resources you are niw denied) overall it is better though since it can in theory be optimized as a whole.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#287

Post by refurb »

wat10000 wrote: post #281
refurb wrote: post #278

Earlier quoted context omitted.

> With private insurers in the US, it means denying care for person A because they think they can get away with it and it will increase their profits. The person at the insurer who denies a claim is not making more money because they denied it. The company as a whole might, but not the person denying it.

Right, the ones who profit are just setting up the rules, policies, and incentive structures that those people work under.

This is a really simplistic approach and you're never going to fix it.

There are numerous stakeholders who setup the rules - the government, insurance companies, hospitals, doctors, billers, etc.

All of them profit from the current system, but there is no single stakeholder who decides the overall rules.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#288

Post by dogboat »

drweevil wrote: post #75

>"An appeal means coaxing your doctor and staff to spend hours filling out forms and making repeated phone calls to joust with an insurance company employee." The hospital where I receive my cancer treatments once told me "don't worry, our Denial Team is handling this." They have a Denial Team. That is to say, insurance companies are imposing cost overheads on providers and patients due to their illegitimate profit b…

"industry malfeasance" is 1984-esque lanuage.

IED airbags, HIV injections, babies without limbs, etc. are industry malfesance.

So the phrase implies:

No acts of corporate greed including profiting by killing people could ever excuse murder.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#289

Post by ethbr1 »

consteval wrote: post #267
ethbr1 wrote: post #205

There's an easy solution to this that the Federal Employee Program (aka FEP) [0] uses -- regular, external accuracy audits. The relevant metric to customers isn't "What percentage of claims are denied?" given the substantial amounts of medical claim fraud. It's "What percentage of claims are denied... that should have been approved ?" So you regularly audit a random sampling of denials, publish the results of that au…

These "bolt on" type of solutions work but they also raise the costs. Already the administration costs of insurance are through the roof. The system is as inefficient as humanly possible. Hospitals needs hundreds of administrators and billing specialists just to make insurance work - never mind the patient and doctor time lost. And now, we also pay to audit insurance? It's too much money burning. This shouldn't be do…

Do you have a source for the administrative costs being larger than they could/should be?

Obviously they'd be lower with single payer, especially on the provider side, but outside of that the system runs pretty efficiently for what it is.

On the provider side, they're going to have to code up a claim.

But once they're submitted, the majority of claims automatically flow through the rest of the system with low human touch.

That's literally the only way insurance companies can function under ACA admin cost caps.

When that generates a denial... then obviously there's a lot more touch during the back and forth.

Re: Feds help health insurers hide their dirty secret: denials on the rise

#290

Post by Eddy_Viscosity2 »

SauciestGNU wrote: post #272
Eddy_Viscosity2 wrote: post #264

Earlier quoted context omitted.

The auditors would either be captured or rendered powerless in short order. There is a great deal of money that can be used for effective lobbying.

Wrongful care denial should be considered a serious felony on par with assault with intent to do grave bodily harm. It should be a veil piercing crime that exposes every insurance company employee involved in denial to personal legal jeopardy should they wrongly deny claims. Reasons for denials must should be required to be extremely detailed and provided to the institutions requesting coverage. Upon receiving a deni…

These are all great 'shoulds' and most people would probably agree. So why do you think there isn't political support for anything close to this?
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